|Year : 2015 | Volume
| Issue : 2 | Page : 245-248
Schulze and Brand type a-IV dens invaginatus with radicular cyst: A rare case report
Rachita Chengappa1, Asim Mustafa Khan1, Kavitha Puttaswamy1, Paul James Kolathingal2
1 Department of Oral Medicine and Radiology, Subbaiah Institute of Dental Sciences, Shimoga, Karnataka, India
2 Department of Conservative Dentistry and Endodontics, Coorg Institute of Dental Sciences, Virajpet, India
|Date of Submission||12-Feb-2015|
|Date of Acceptance||19-Oct-2015|
|Date of Web Publication||21-Nov-2015|
Asim Mustafa Khan
Department of Oral Medicine and Radiology, Subbaiah Institute of Dental Sciences, Purale, Shimoga - 577 222, Karnataka
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Though a clinical examination may reveal a deep fissure or pit on the surface of an anterior tooth, radiographic examination is a more accurate approach to diagnose an invagination. Dens invaginatus is one of the common dental deformities, but the defect involving the root and its association with radicular cyst is still very uncommon. The objective of this case presentation is to report a case of radicular dens in dente, which is a rare dental anomaly. This case report shows that dens invaginatus with an open apex and a radicular cyst can be treated successfully using currently available materials.
Keywords: Dens in dente, dens invaginatus, radicular cyst
|How to cite this article:|
Chengappa R, Khan AM, Puttaswamy K, Kolathingal PJ. Schulze and Brand type a-IV dens invaginatus with radicular cyst: A rare case report. J Indian Acad Oral Med Radiol 2015;27:245-8
|How to cite this URL:|
Chengappa R, Khan AM, Puttaswamy K, Kolathingal PJ. Schulze and Brand type a-IV dens invaginatus with radicular cyst: A rare case report. J Indian Acad Oral Med Radiol [serial online] 2015 [cited 2019 May 26];27:245-8. Available from: http://www.jiaomr.in/text.asp?2015/27/2/245/170146
| Introduction|| |
Dens invaginatus is a developmental abnormality resulting in extention or invagination of the enamel organ into the dental papilla before the calcification of dental tissues.  Dens invagination in a human tooth was first described by a dentist named Socrates in 1856.  Dens invaginatus has many synonyms like dens in dente (Busch, 1897), dilated composite odontome (Hunter, 1951), dents telescope, and gestant anomaly (Colby, 1956). But dens invaginatus (Hallet, 1953) seems to be the most suitable as it indicates the infolding of the outer portion (enamel) into the inner portion (dentine) with the formation of a pocket or dead space. 
Dens invaginatus is one of the common dental deformities, but the defect involving the root is still very uncommon. More and Patel (2012) reported that 37.33% of cases diagnosed with dens invaginatus were associated with underlying cysts.  A simple deep carious lingual pit should be a starting point for further investigations. Identification of such features becomes imperative in clinical practice to avoid further complications.  The aim of this case presentation is to report a case of radicular dens in dente associated with a radicular cyst.
| Case Report|| |
A 46-year-old female reported with a chief complaint of decayed tooth with respect to the upper left front teeth region since 4 months. There were no other associated symptoms. There was no significant medical history. Extraoral examination revealed no abnormalities. Intraoral examination revealed retained deciduous maxillary left canine with deep cervical caries [Figure 1]. Maxillary left lateral incisor was discolored with a faint longitudinal palatal groove. The contralateral lateral incisor appeared normal. A diffuse palatal expansion was noted in relation to the left lateral incisor, with no bony decortications. Patient was unaware of the palatal swelling [Figure 2].
|Figure 1: Clinical picture showing discolored permanent maxillary left lateral incisor and retained deciduous maxillary left canine|
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Radiographic investigation revealed horizontally impacted permanent left maxillary canine. Dense invaginatus was seen in relation to the permanent left maxillary lateral incisor, originating from the incisal edge as a linear longitudinal radiolucency and extending up to the middle third of the mesial side of root. Linear radiolucency was surrounded by dense, radiopaque linear border. The coronal invagination extending up to the root had caused the root to divide into a mesial accessory segment. A well-defined, uniform periapical radiolucency with scalloped borders was associated with the lateral incisor suggestive of a radicular cyst [Figure 3] and [Figure 4].
|Figure 3: Intraoral periapical (IOPA) radiograph showing the defect extending along the root|
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|Figure 4: Panoramic radiograph showing extent of the radiolucency and horizontally impacted left maxillary canine|
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The impacted canine was surgically removed, along with excision of the cystic lesion and removal of the dysmorphic root segment. Histopathologic examination of the cystic lesion revealed a radicular cyst. The resection of the accessory root segment of the left lateral incisor was followed by root canal treatment and retrograde filling with mineral trioxide aggregate (MTA) [Figure 5] and [Figure 6].
|Figure 6: IOPA radiograph showing root canal treatment (including obturation of mesial root) and retrograde filling with MTA|
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| Discussion|| |
The prevalence of dens invaginatus ranges from 0.04 to 10%.  Shafer has reported a prevalence of 1.3% in 2542 full-mouth surveys.  Grahnen et al. have reported a prevalence of 2.7% in a study of 3020 lateral incisors and also reported that in 43% patients, it occurred bilaterally.  In 1997, Hülsmann reported that maxillary lateral incisors are most commonly affected, with the posterior teeth less likely to be affected.  This is supported by the study of Hamasha and Al-Omari who reported that in 1660 subjects examined, 90% of the affected teeth were lateral incisors and only 6.5% were posterior teeth. 
Over the last decades, several theories have been suggested to describe the etiology of dens invaginatus, some of which are as follows:
- Retardation of a focal group of cells from proliferating normally (Kronfeld, 1934). 
- Fast and aggressive proliferation of a part of the internal enamel epithelium invading the dental papilla (Rushton, 1937). 
- Distortion of the enamel organ during tooth development and subsequent protrusion of a part of the enamel organ leading to the formation of an enamel-lined channel ending at the cingulum (Oehlers, 1957). 
- External forces exerted on the tooth germ during development (Atkinson, 1943). 
- Trauma (Gustafson and Sundberg). 
- Fusion of two tooth germs ("twin-theorie"). 
- Lack of chromosome 7q32 (Grahnen et al.). 
- Infolding of Hertwig's sheath (Bhatt and Dholakia). 
The first classification of invaginated teeth was proposed by Hallet (1953). However, the most commonly used classification was proposed by Oehlers (1957). He described the anomaly occurring in three forms: 
Type I: An enamel-lined minor form occurring within the confines of the crown and not extending beyond the amelocemental junction.
Type II: An enamel-lined form which invades the root, but remains confined as a blind sac. It may or may not communicate with the dental pulp.
Type III: A form which penetrates through the root perforating at the apical area, showing a "second foramen" in the apical or in the periodontal area. There is no immediate communication with the pulp. The invagination may be completely lined by enamel, but frequently, cementum will be found lining the invagination.
Schulze and Brand (1972) suggested a detailed classification, with invaginations beginning at the incisal edge or the top of the crown and also including dysmorphic root shapes. The classification has been divided into groups a and b with four different variations described in each group. In the first group, the invagination causes division of enamel and dentin. In the second group, the invagination causes division of pulp chamber into two, along with enamel and dentin. 
Oehlers' classification is less suitable in our case. Rather, our case resembles the fourth variant of group-a described by Schulze and Brand, where the invagination involves the root with a dysmorphic root, with no division of the pulp chamber. Oehlers' system is based on a two-dimensional radiographic image and, as such, may underestimate the true extent and complexity of the invagination. With the advent of three-dimensional imaging, the complex anatomy of dense invaginatus can be better defined, further aiding in better treatment planning.
Teeth with dense invaginatus are more prone to infections because the abnormal anatomy paves way for entry of irritants resulting in pulpal inflammation and necrosis. More often, the condition is incidentally diagnosed on radiographic examination. Early detection of this condition is essential to avoid associated complications. If detected early, prophylactic sealants are indicated.
| Conclusion|| |
Dens invaginatus is clinically significant due to the possibility of pulpal involvement and chronic periapical lesions. Therefore, early diagnosis and preventive measures are helpful to prevent complications. This case report shows that dens invaginatus with an open apex and a radicular cyst can be treated successfully with the better evolved current diagnostic and treatment modalities.
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Conflicts of interest
There are no conflicts of interest.
| References|| |
Hülsmann M. Dens invaginatus: Aetiology, classification, prevalence, diagnosis, and treatment considerations. Int Endod J 1997;30:79-90.
Schulze C. Developmental abnormalities of the teeth and jaws. In: Gorlin RJ, Goldman HM, editors. Thoma's Oral Pathology. St Louis: CV Mosby; 1970. p. 112-22.
Khanna S, Purwar A, Gulati R, Sharma D. Concurrence of dens invaginatus and evaginatus involving all maxillary anteriors: A rare case with comprehensive review. IOSR J Dent Med Sci 2013;6:59-62.
More CB, Patel HJ. Dens Invaginatus: A Radiographic Analysis. 2012 July; omicsonline.org 1: 147. Available from: http://omicsonline.org/scientific-reports/2167-7964-SR147.pdf. [Last accessed on 2015 Jan 05].
Attur KM, Shylaja, Mohtta A, Abraham S, Kerudi V. Dens invaginatus, clinically as talon cusp: An uncommon presentation. Indian J Stomatol 2011;2:200-03.
Munir B, Tirmazi SM, Majeed HA, Khan AM, Iqbalbangash N. Dens invaginatus: Aetiology, classification, prevalence, diagnosis and treatment considerations. Pakistan Oral Dent J 2011;31:191-8.
Shafer WG. Dens in dente. N Y State Dent J 1953;19:220-5.
Grahnen H, Lindahl B, Omnell K. Dens Invaginatus. I. A clinical, roentgenological and genetical study of permanent upper lateral incisors. Odontologisk Revy 1959;10:115-37.
Hamasha AA, Al-Omari QD. Prevalence of dens invaginatus in Jordanian adults. Int Endod J 2004;37:307-10.
Bhatt AP, Dholakia HM. Radicular variety of double dens invaginatus. Oral Surg Oral Med Oral Pathol 1975;39:284-7.
Oehlers FA. Dens invaginatus (dilated composite odontome). I. Variations of the invagination process and associated anterior crown forms. Oral Surg Oral Med Oral Pathol 1957;10: 1204-18 contd.
Schulze C, Brand E. Über den Dens invaginatus (Dens in dente). ZWR 1972;81:569-73, 613-20, 653-60, 699-703.
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]